Eyes, Mouth and Trachea

Expose the conjunctiva looking for pallor. Inspect the oral cavity. Candidiasis may indicate immunosuppression or use of inhaled corticosteroids.

Tracheal deviation is a reliable clinical sign when properly performed. To assess its position ask to patient to face straight forward and relax the neck musculature. Place a single finger in the suprasternal notch and gently push forward until the cartilaginous trachea is felt. Gently feel to either side of the cylindrical structure and estimate its position relative to the middle of the supraclavicular notch. This can be uncomfortable for the patient so clearly explain why you are doing this and be as gentle as possible. Perform it on yourself to gauge how firmly you can palpate before causing discomfort.

A trachea deviated from the midline has either been pushed or pulled by a significant anatomical abnormality, usually in the lung apices or mediastinum. The trachea will be pushed away from a large pneumothorax or mass and will be drawn towards collapse or fibrosis. Surgical resection of a lobe or more of a lung (notice thoracotomy scars) will often result in deviation. Occasionally distortion of the chest wall by severe kyphoscoliosis can result in apparent deviation without underlying parenchymal disease.